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GHSA Associate Membership Application - Check Payments

IMPORTANT INFORMATION: PLEASE READ BEFORE COMPLETING APPLICATION!
If you work for a State Highway Safety Office or existing GHSA Associate Member, you are already considered a member of GHSA.

GHSA Associate Members must agree to support the goals and objectives of GHSA and may not vote on Association policies. Associate Member dues support the general purposes of GHSA, including publications, training and research.

The GHSA Executive Board reviews all Associate Member applications quarterly (March, June, August, December). You will be notified after the next Board Meeting whether your application has been accepted. Associate Membership does not imply GHSA endorsement or grant permission to use the GHSA logo.

**** GHSA does not offer pro-rated memberships.

* Applications reviewed at the June, August/September and December meetings include membership through the current fiscal year, which ends on June 30.

* Applications approved at the March meeting will be approved for the remainder of the fiscal year and the following fiscal year, which begins on July 1.

Select Associate Membership Price *

$1,000 - Corporate (4+ employees)

$750 - Public Service (State, local or tribal government agency (Requires State Highway Safety Office approval)

$550 - Non-Profit (must provide IRS letter indicating 501(c)(3) tax exempt status)

$450 - Small Business (1-3 employees, including individual consultants)

$250 - Emeritus (former GRs/Coordinators)

Upload your IRS letter or tax-exempt certificate

Payment

DUES PAYMENT
GHSA bylaws specify that Associate Member dues be assessed at the time of application.

For any financial questions or concerns, please contact Lisa Wagner at lwagner2@ghsa.org or 202-580-7929.

If your application is rejected, your dues payment will be refunded.

Your organization's application will not be considered for Board approval until payment is received.

If paying by check, please mail your payment to:

GHSA Associate Member Dues
660 North Capitol Street NW, Suite 220
Washington, D.C. 20001-1642

Please contact Wilnie Petrash at wpetrash@ghsa.org or 202-580-7929 with any questions concerning a check payment.

Organizational Information

Organization *

Street Address *

Address Line 2

City *

State/Province *

Zip Code *

Phone Number *

Email Address *

Website *

Social Media Handle: X/Twitter

Social Media Handle: Facebook

Social Media Handle: LinkedIn

Which of the following categories best describes your organization? Please select ONE of following options below. If you believe your organization falls under more than one category or under a different category not listed, please email Kerry Chausmer (kchausmer@ghsa.org) for further assistance. *

Automotive Industry - Automakers or organizations who represent them.

Enforcement - Organizations or individuals from or representing the law enforcement community.

Insurance Industry - Insurance providers or organizations who represent them.

Issue Advocacy - Organizations or individuals who advocate for various traffic safety issues at the local, state, or national level.

Law Firm - Attorneys who represent individuals who have been injured in traffic crashes.

PR/Communications/Marketing - Organizations or individuals who conduct public relations, communications or marketing efforts to advance traffic safety.

Product Providers - Companies that provide specific products and/or services such as ignition interlocks, grants management platforms, or traffic records software.

Public Service - State, Local or Tribal Agency

Researchers & Consultants - Organizations or individuals who conduct research or consult on traffic safety issues.

Primary Contact Information

First Name *

Last Name *

Title *

Street Address *

Address Line 2

City *

State/Province *

Zip Code *

Phone Number *

Email Address *

How did you hear about GHSA? *

0/500 words

Why are you interested in becoming a member of GHSA? What are your expectations of membership? *

0/500 words

Web Listing

GHSA maintains a web page with the logos and descriptions of all our Associate Members.

Please upload your logo for display on our website. *

In your own words, briefly describe your product or service (please do not cut and paste a marketing message). *

0/500 words